Disinhibited social engagement disorder

Disinhibited social engagement disorder (DSED), or disinhibited attachment disorder, is an attachment disorder in which a child has little to no fear of unfamiliar adults and may actively approach them. It can significantly impair a young child's ability to relate with adults and peers, according to the Diagnostic and Statistical Manual of Mental Disorders,^[3] as well as put them in dangerous and potentially unsafe conditions, as they may, for example, walk off with a complete stranger in a public place.^[4]

Disinhibited social engagement disorder
Other names	Disinhibited attachment disorder
Specialty	Psychiatry
Usual onset	After 9 months of age[1]
Causes	Child neglect
Differential diagnosis	Attention deficit hyperactivity disorder[2]

DSED is exclusively a childhood disorder. It is usually diagnosed after nine months, but before age 6. Some signs of DSED may present into adolescence and young adulthood.^[5][6] Infants and young children are at risk of developing DSED if they receive inconsistent or insufficient care from a primary caregiver. Like reactive attachment disorder, it is commonly diagnosed in children raised in foster care or institutional environments.^[4]

Signs and symptoms

The most common symptom of DSED is unusual interaction with strangers. A child with DSED shows no sign of fear or discomfort when talking to, touching, or accompanying an adult stranger.^[3] These behaviors can be categorized by the following:

• Overly familiar verbal or physical behavior that is not consistent with culturally sanctioned and appropriate social boundaries, or seems out of character for their current age
• Lack of reservation when approaching and interacting with unfamiliar adults
• Diminished or absent checking back with an adult caregiver after venturing away, even in unfamiliar settings
• Willingness to go off with an unfamiliar adult with minimal or no hesitation ^[7]

A disorganized attachment style is associated with DSED. Disorganized attachment is common amongst children living in institutions such as foster care. Children living in these institutions have an increased risk of DSED.^[8]

DSED can cause symptoms commonly associated with attention deficit hyperactivity disorder (ADHD), and can be comorbid with cognitive, language and speech delay.^[9] Additionally, children who are socially disinhibited but who have not experienced neglect should not be diagnosed with DSED. In such cases, the child's behavior can be explained with other disorders such as Williams syndrome, which often has similar symptoms to DSED.^[10]

Risk factors

DSED is a result of negligent, absent, or inconsistent primary caregivers in the first few years of childhood.^[11] Children who are institutionalized may receive inconsistent care or become isolated during hospitalization (as when children may be cared for by many different staff members during an inpatient stay).^[8][12] Parental issues such as mental health problems, depression, personality disorder, absence, poverty, teen parenting, or substance abuse interfere with attachment.^[13]

Diagnosis

The ICD-10 definition is: "A particular pattern of abnormal social functioning that arises during the first five years of life and that tends to persist despite marked changes in environmental circumstances, e.g. diffuse, nonselectively focused attachment behavior, attention-seeking and indiscriminately friendly behavior, poorly modulated peer interactions; depending on circumstances, there may also be associated emotional or behavioral disturbance."^[14]

Differential diagnosis can be attention deficit hyperactivity disorder.^[9]

Adolescents who exhibit symptoms of DSED can often be misdiagnosed due to several contributing factors, such as a history of neglect, an overidentifying or misidentifying of symptoms through incorrect differential diagnosis, and disregarding comorbid conditions that could account for their symptoms.^[15][16][17]

However, it is essential^[why?] to mention the intersectionality between contributing factors and DSED and how they influence the symptomatic behavior of children diagnosed with DSED. For example, adolescents diagnosed with DSED and ADHD experience overlapping symptoms that are essential to identify in order to make appropriate diagnoses and treatment plans.^[18]

Treatment

Two effective treatment approaches are play therapy or expressive therapy which help form attachment through multi-sensory means. Some therapy can be nonverbal.^[19]

Prognosis

Over time, the nature of the behaviors of a child with disinhibited social engagement disorder can evolve during their preschool, middle school, and adolescence years.

Preschool: In this early stage DSED is exhibited by a need for attention such as being overly boisterous^[vague] at the playground in attempts to get the attention of unfamiliar adults.

Middle School: There are two main identifiers of DSED in this stage including physical and verbal overfamiliarity of inauthentic emotions and being overly forward. This can be seen^{[by whom?]} as appearing sad in front of others in efforts to manipulate a social situation or being overly insistent upon going over a classmate's house when they first meet them.^{[citation needed][relevant? – discuss]}

Adolescent: Amongst this stage children with DSED are likely to develop problems^{[example needed][vague]} with their peers and other authority figures such as parents and coaches. "They [also] tend to develop superficial relationships with others, struggle with conflict, and continue to demonstrate indiscriminate behavior toward adults." ^[7]

Epidemiology

The exact prevalence is unknown. In high-risk individuals, the prevalence rate is 20%.^[20]

History

Disinhibited Social Engagement Disorder (DSM-5 313.89 (F94.2)) is the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) name formerly listed as a sub-type of reactive attachment disorder (RAD) called disinhibited attachment disorder (DAD).

According to the American Psychiatric Association, "...Disinhibited Social Engagement Disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments. The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders."^[21]

Research

In a study aiming to show that reactive attachment disorder and DSED were separate concepts, a sample of school aged foster children were tested and their foster parents, and social workers completed questionnaires to better understand the children and to pinpoint signs of DSED. Amongst completion it was evident that DSED was indeed its own separate dimension of psychology.^[22]

See also

• Reactive attachment disorder
• Attachment style